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MRCOG PART 2 SBAs and EMQs

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EMQ1478
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A 24 years old nulliparous woman complains of heavy painful menstrual periods and abdominal distensi

A 24 years old nulliparous woman complains of heavy painful menstrual periods and abdominal distensi Posted by Nibedita R.


Large uterine fibroid is the cause of heavy painful menstruation in this woman and needs urgent treatment in these circumstances.
Careful history related to menstruation ( length of menstrual cycle, duration of bleding, amount ogf loss, pasage of clots), character of pain and its relation with the menstrual cycle, intermenstrual bleeding, contact bleeding and pressure symptoms(bowel and bladder) should be evaluated before treatment is offerred.

Fertility may be a problem in this situation ( large cornual fibroid or submucous fibroid may interfere with conception and may be a causative factor for miscarraige). Reassurance should be given that fertility and pregnancy is likely to be normal.

Advice should be given that if pregnancy occurs with fibroid, complications like miscaraige, pain due to red degeneration, increase risk of caesarean section due to malpresentation or labour related problems and third stage complications may happen.

Examination includes assessing the severity of blod loss (pallor), abdominopelvic examination( to rule out cervical fibroid) and bimanual examination.

The choice of treatment will depend on the site and number of fibroid. Hence, location and number of fibroid must be comfirmed by high resolution ultrasound scan by an expert sonlogist.

Treatment options available are medical and surgical.
Medical treatment:
The most effective medication is Gonadotropin Releasing Hormone Agonist (GnRHa). This can ease heavy periods and pressure symptoms. However, it may also increase the risk of osteoporosis. Therefore, this treatment is not given for a long term. It may be used to shrink large fibroids prior to surgery. More recently a combination of GnRHa plus \'Add Back\' hormone replacement therapy (HRT) with low oestrogen has been used to shrink the fibroid and to prevent menopausal side efffects. Reversal of symptoms after discontinuation of therapy should be considered.
The following mediations are also used to treat heavy periods, whatever the cause:
Tranexamic acid
Antiinflammatory medications
The contraceptive pill may help with period pain and also acts as effective contraceptive if the woman do not want pregnancy.
Levonorgestrel intrauterine system is helpful in reducing amount of flow and also for shrinkage of fibroid.

Uterine artery embolisation is a new technique and it safety after pregnancy is unproven. it should therefore be considered as part of a randomised controlled trial.

Surgery should be considered in the case of failed medical treatment or a submucous fibroid.

Counselling for surgery must include the implications of myomectomy and the complications of major surgery. the chance of hysterectomy should not be ignored and thte risk of future pregnancy with uterine scar.

The patient should be provided with information leaflets and informed consent should be taken before operation.
The patient should be made aware that the need for surgery will increase, the longer she defers surgery.